Eyeworld

60 | EYEWORLD | FALL 2025 G UCOMA Reference 1. Gazzard G, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre ran- domised controlled trial. Lancet. 2019;393:1505–1516. by Manjool Shah, MD Glaucoma Editor A s we navigate the dynamic landscape of innovation, it's crucial to remem- ber that progress requires owning and under- standing the past in order to be open to the future. This issue powerfully illustrates this synergy by delving into the nuances of specific glaucoma types and showcasing advancements in a well-established treatment modality. The principle of continuous improvement, driven by the desire for greater standardization and predictability, is nowhere more evident than in the advent of direct selective laser trabecu- loplasty (DSLT). Jella An, MD, Shamik Bafna, MD, and Christine Funke, MD, discuss DSLT and how they've incorporated it into practice. The LiGHT trial 1 has already demonstrated that selective laser trabeculoplasty (SLT) is a superior first-line therapy compared to drops, showing better long-term outcomes and less vi- sual field progression. Despite this evidence, the "manual" SLT procedure has often been consid- ered cumbersome. This is precisely where DSLT shines as a revolutionary advancement. From increased surgical efficiency to an optimization of patient and surgeon ergonomics and comfort, DSLT is particularly compelling in an era where demographics and physician attrition requires us to think very critically about ways to handle the large number of patients we will need to take care of in the future. While some limitations exist, such as the need for accurate limbal detection in certain patients and the learning curve for integrating it into clinic flow, the consensus is that DSLT has the potential to completely revolutionize how we do SLT. It signifies a shift in mindset, prompting us to push the envelope and offer this technology earlier in the treatment para- digm, before extensive medication burden and tissue damage occur. Jonathan Eisengart, MD, Davinder Gro- ver, MD, MPH, and Kateki Vinod, MD, provide a timely and comprehensive discussion on pigment dispersion syndrome (PDS) and pig- mentary glaucoma (PG). This condition arises from the friction between the iris and zonules, liberating pigment that can clog the trabecular meshwork and elevate IOP. Key clinical findings include the Krukenberg spindle, iris transillumi- nation defects, and a heavily pigmented trabec- ular meshwork. The condition is most common in younger (40–60 years old), myopic male patients. The article serves as an important reminder that while PDS can "burn out" over time, the lifelong risk of glaucoma persists. When it comes to treatment, clinicians must be particularly vigilant. While SLT is consid- ered a "tremendous option" for PG, its appli- cation requires careful consideration due to the increased risk of post-laser pressure spikes from excess pigment. Experts advise treating only a limited part of the angle (e.g., 90 or 180 degrees) with lower energy settings, followed by close IOP monitoring. The article also wisely cautions about the potential for IOP spikes with certain MIGS procedures in PG patients, reminding us that even the latest innovations demand tailored application. The discussions in this issue vividly remind us that while our tools and techniques evolve, the core principles of meticulous diagnosis, in- dividualized treatment, and a patient-centered approach remain paramount. The challenges we face in glaucoma care, whether it's understand- ing complex conditions like pigmentary glauco- ma or adopting transformative technologies like DSLT, are the very impetus for our continuous innovation and growth. Innovation and growth in glaucoma care The discussions in this issue vividly remind us that while our tools and techniques evolve, the core principles of meticulous diagnosis, individualized treatment, and a patient- centered approach remain paramount.

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